Working Successfully with Health Plans

This document, based in part on an expert panel meeting, outlines a three-part process to “explore challenges family planning centers face in contracting with Medicaid and private health plans—a step that is increasingly necessary for centers to remain viable as health care providers.”

Observations and recommendations are particularly important as the Affordable Care Act (ACA) opens up new insurance options for clients. With these changes in payers, Ryan White providers need to establish contractual relationships with health plans and Medicaid Managed Care Organizations in order to position themselves to continue to serve their clients and receive reimbursement for services delivered.

This document outlines three steps for agencies to undertake in contracting with health plans:

Preparation. Specifics include: assess the agency’s readiness and costs of its services in terms of the number of current clients, their payer sources, staff skills to handle coding and billing; capacity of the health information technology system; examining the health marketplace in terms of key health plans and provider networks as potential contract partners; and determining the cost of services as an agency does not want to contract for services with a payer if the negotiated rates are going to be insufficient to cover costs).

Negotiating Contracts. This is the point at which an agency lets plans know what they bring to the table (e.g., experience insuring and reporting quality of care, especially the Healthcare Effectiveness Data and Information Set (HEDIS), tool of the National Committee for Quality Assurance (NCQA). Contract negotiations also take place regarding reimbursement rates and discussions on other contractual issues (e.g., filing claims).

Operating Under Plan Contracts. Key areas include credentialing of staff (which is reportedly a potentially time consuming effort) and handling billing and reimbursement according to plan requirements.